S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Project Connect Twin Oaks Juvenile Development Corporation (Contract Provider) 2930 Kerry Forest Parkway, Suite 101 Tallahassee, Florida 32309 Review Date(s): February 22 & 23, 2017 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES
Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Warren Garrison, Office of Program Accountability, Lead Reviewer (Standard 1, 2, & 3) Lauren Floyd, Probation Headquarters, Government Operation Consultant II (Standard 2& 3) Juan Youman, Office of Program Accountability, Operation Review Specialist (Standard 2 & 3)
Program Name: Project Connect MQI Program Code: 1307 Provider Name: Twin Oaks Juvenile Development Corporation Contract Number: 10113 Location: Leon County / Circuit 2 Number of Beds: Review Date(s): February 22 & 23, 2017 Lead Reviewer Code: 122 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment Services, and (3) Intervention Services, which are included in the Transition Services Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook # Health Records # MH/SA Records 11 # Personnel Records 17 # Training Records/CORE 11 # Youth Records (Closed) 27 # Youth Records (Open) 55 # Other: Volunteers # Youth # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Comments Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 14 (Revised July 2016)
Standard 1: Management Accountability Transition Services Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Pre-Service and/or In-Service Training 1.04 Incident Reporting (CCC)* 1.05 Abuse reporting (DCF)* 1.06 Administration 1.07 JJIS and Data Requirements * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 14 (Revised July 2015)
Standard 2: Assessment Services Transition Services Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Referral Process 2.02 Admission and Services Provision Processes 2.03 Assessments for Services * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 14 (Revised July 2015)
Standard 3: Intervention Services Transition Services Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Individualized Plan of Care 3.02 Community Referrals 3.03 Transition Services Case Management 3.04 Release/Discharge * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 14 (Revised July 2015)
Strengths and Innovative Approaches The implementation of an improved statistical analysis system enabled the program to implement unique strategies to improve our assistance to our partners. Utilizing the SharePoint-based database and the Department s weekly commitment listing, Project Connect was able to generate a tracking system for all North Region commitments to assist in identifying youth who are eligible for referral for transition/aftercare services, who had not yet been referred. The implementation of this tool enhanced reconciliation of committed youth eligible for services. The on-line database also enables Project Connect to identify issues related to CPACT (Community based Positive Achievement Change Tool) scoring, which led to the development of a template email tool to identify youth domain improvement on a monthly basis. Project Connect experienced a 14.2% recidivism rate for in-service youth and an 18% recidivism rate for youth released from the program in 2016, compared to the 44% for the same, post-commitment population, prior to Project Connect transitional services being implemented. The program, through a strategic partnership with Wells Fargo Bank Florida, gives online and instructor-led financial literacy course access to all youth in the program and their families. The courses offered by Wells Fargo cover all aspects of financial literacy from an elementary school level through retirement age. Office of Program Accountability Page 7 of 14 (Revised July 2015)
Standard 1: Management Accountability Overview Project Connect is the transitional services contract for the Department of Juvenile Justice s North Region of Florida, which includes Circuits 1, 2, 3, 4, 5, 7, 8, and 14. The contract is operated by Twin Oaks Juvenile Development Corporation. The Circuits are separated into three regions, the Northwest area (Circuits 1, 2, 3, & 14), the Northeast area (Circuits 4 & 8), and the Northcentral area (Circuits 5 & 7). Each area is assigned an area director and a lead transition specialist. The program employs a program director, director of training and operations, three area directors, director of education and vocation, director of human resources, two administrative assistants, thirty-three transition specialists, and fifty-five life coaches. The program currently has one vacant transition specialist positon in Circuit 1. The program director of training and operations is responsible for all training of staff and the administrative assistants are responsible for background screenings of all staff and life coaches. The program utilizes the Department s Background Screening Policy and Procedures for all newly hired staff and staff requiring rescreening every five years after employment. At a minimum, all staff must complete training in the following areas: motivational interviewing, critical incident reporting, Juvenile Justice Information System (JJIS), Central Communications Center (CCC) reporting, trauma informed care training, and civil rights.. 1.01 Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The program employed ten new staff during this recent annual compliance review period. A new background screening was completed for each of the newly employed staff. None of the newly hired staff were rated ineligible. The program also employed three newly hired life coaches. A new background screening was completed for each of the newly hired life coaches and none of the life coaches were rated ineligible. None of the new hires were hired prior to a background screening being completed by the program. The Affidavit of Compliance with Level 2 Screening Standards was submitted to the Background Screening Unit (BSU) on January 30, 2017. 1.02 Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program had one staff eligible for a five-year rescreening. A rescreening was submitted to the Background Screening Unit (BSU) at least ten business days prior to their five-year anniversary date. In accordance with Level 2 standards, as set forth in Chapter 435, Florida Statutes, the staff met retention for their current position after reviewing the results of the screening. Office of Program Accountability Page 8 of 14 (Revised July 2015)
1.03 Pre-Service and/or In-Service Training Compliance All Transition Services staff shall successfully complete training requirements as set forth in the standards. The training shall be completed prior to the delivery of direct services to Department youth and/or as in-service training to Transition Services staff. A review of ten pre-service training files revealed nine staff were eligible to have completed the required training, prior to the delivery of direct services. Each of the nine staff had documentation in the staff training files of completing training in motivational interviewing, critical incident reporting, Juvenile Justice Information System (JJIS), Central Communications Center (CCC) reporting, trauma informed care training, adolescent brain development, and civil rights. 1.04 Incident Reporting (CCC)* Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. During this recent annual compliance review period, four Central Communications Center (CCC) reports were reported by the program. A review of all CCC reports for the program revealed consistency with the Departments requirements. All were reported to the CCC within two hours of the program learning of the incident. Reports included basic information known at the time the report was made, including the names of the youth and staff involved, the nature of the incident, the time and location and, an incident number generated by the Department. 1.05 Abuse Reporting (DCF)* Compliance Any person who knows, or has reasonable cause to suspect, a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. The program has a policy to promote and ensure an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. The policy addresses and states their code of conduct forbidding staff from using physical abuse, profanity, threats or intimidation, allegations of child abuse or suspected child abuse are to immediately be reported to the Florida Abuse Hotline and youth have unimpeded access to self-report alleged abuse and the abuse hotline number is to be posted throughout the program. The program had documentation of staff having to report abuse on behalf of a youth. No allegations were made against program staff. 1.06 Administration Compliance The Program/Provider shall provide a safe and appropriate treatment environment including administrative and operational oversight. The program provided documentation of maintaining information on the facility and reporting it to the Department. Monthly reports were submitted to the Department detailing incidents and population data. Each of the twenty-seven youth reviewed matched the census report in the Office of Program Accountability Page 9 of 14 (Revised July 2014)
Juvenile Justice Information System. Statistical information was maintained, including data on admissions releases, transfers, absconders, abuse reports, medical and mental health emergencies, incidents, personnel actions, and average length of stay. Monthly reports included youth monthly progress report, monthly service summary reports, discharge summary reports, fidelity monitoring report, compliance monitoring reports, staff vacancy reports, youth census reports, invoices, and youth services reports. 1.07 JJIS and Data Requirements Compliance The Program/Provider and subcontracted service providers shall utilize the Department s Juvenile Justice Information System (JJIS) for data entry and shall monitor accuracy at all times. The program utilized the youth placement facility module for referral acceptance, rejection, and placement. Twenty-seven files were reviewed. Referrals were made by the Department were reviewed and accepted within 72 hours of the referral. The youth release module was used to complete all releases and there were up-to-date census reports for all youth currently being served. Each of the twenty-seven files reviewed had documentation of the program entering the youth as released from their services in the Juvenile Justice Information System (JJIS), within twenty-four hours of their release. The program maintained their own reports. Staff verification data was maintained by the provider, utilizing the Staff Verification System (SVS) module. The date of youth admission for service, date of discharge/release for eleven closed files, and release reason for each youth was reported in JJIS. Standard 2: Assessment Services Overview Male and female youth, age eleven and older, on conditional release, post-commitment probation, probation, or who have been direct discharged are eligible to participate in the program. Referrals are made by the youth s juvenile probation officer (JPO), no later than 90 days prior to residential program release. For youth referred while in a residential commitment program, pre-service activities begin once the referral is accepted, however placement does not begin until a youth physically returns back to the community and an intake and admission occurs. Services begin within four (4) business days of release from the residential facility. The youth s JPO and JPO supervisor review and discuss the referral within seventy-two (72) hours. Upon receiving a referral, the transition specialists, in collaboration with the area directors, view the youth s educational records, pre-disposition/post disposition report, and Positive Achievement Change Tool (PACT) overview report, transitional documents, recommendations and progress in the program, exit staffing documents, and when available the educational transition plan. In addition to the services provided, the transitional specialist provides the youth with opportunities to earn industry recognize certificates, in the Florida Ready to Work credential, and to gain employability skills training, life skills training, and independent living skills training. Office of Program Accountability Page 10 of 14 (Revised July 2015)
2.01 Referral Process Compliance Program/Provider shall review each referred youth s referral via email and JJIS to assess the youth s service needs and shall accept or reject all DJJ youth referred for transition services within seventy-two (72) hours of referral from the Department (excluding weekend and holiday hours). Twenty-seven open youth records were reviewed. The program admitted each youth in JJIS upon placement. Each of the youth were physically back in the community. Each procedure for a youth accepted or rejected for service was in accordance with the contract. Interviews with three area directors confirmed staff are aware of how the contract delineates the process of accepting of rejecting a referral. Documentation included the program contacting the youth s juvenile probation officer (JPO) and JPO s supervisor, by email, to review and discuss the referral within seventy-two hours, pursuant of the contract. 2.02 Admission and Services Provision Processes Compliance A referral and/or pre-service activities shall begin while the youth is in a residential commitment, however, placement does not begin until a youth physically returns back to the community. Twenty-seven open youth records were reviewed. Of the twenty-seven open youth records, twenty-four were accepted, prior to release from a residential program. A transition specialist was assigned in each case and documentation of the transition specialist conducting preservice tasks was included in the youth records. Pre-service tasks included participation in the community re-entry team meetings, contacts with the youth s family, and transitional planning. Each of the twenty-four youth admitted prior to release from a residential program were oriented into the program within four days of release, and within seven days for the three youth records documenting services were rendered after release from a residential program. 2.03 Assessments for Services Compliance Transition Services providers shall conduct a Service Needs Assessment. The purpose of the assessment is to further define each youth s specific service needs as related to the core services. Twenty-seven youth records included documentation of the transitional specialist completing a triangulation of transitional needs assessments including: a collection of collateral information, interviews conducted with the youth, family, juvenile probation officer (JPO), and residential staff, and youth assessments. Office of Program Accountability Page 11 of 14 (Revised July 2015)
Standard 3: Intervention Services Overview Transitional services are the services provided to youth to facilitate a successful, normalized transition from a residential commitment program through the first three to six months of their return to their communities. Services are focused on four core areas: education, vocation, transportation, and mentoring. These services are rendered in accordance with a youth-centric, individualized service plan (ISP), including input from the youth, parents, residential staff, juvenile probation officers, education/vocation professionals, clinical providers, and related assessments and evaluations. Pursuant of the contact, the following three agencies have significant roles in each youth s Community Action Team: the local school district, the local Workforce Board, and the local Boys & Girls Club. 3.01 Individualized Plan of Care Compliance Program/Provider shall provide service planning for each youth with a youth-centered approach taking into consideration all the youth s service needs. The Individualized Service Plan (ISP) shall indicate goals to facilitate successful reentry to the community. Documentation in twenty-seven open youth records included a face-to-face contact with the youth every two weeks, to address the status of the Individualized Service Plan (ISP). Each ISP was reviewed monthly, by the transitional specialist, during the community action team meeting. The ISP identified the youth needs including transportation, vocational job placements, educational goals, and life skills. 3.02 Community Referrals Compliance The provider shall have established links with other local community organizations to ensure the supportive service needs of the youth can be met in accordance with their individualized service plan. Twenty-seven open youth records were reviewed. Two were applicable for this indicator, due to the program completing a referral to a local community organization. Each referral was maintained in the individual youth record. Each referral reflected the referral type, community organization, referral date, the acquisition date, and referral end date. In each case the transitional specialist notified the juvenile probation officer (JPO) of services and followed-up with each referral within fourteen days of services being identified. 3.03 Transition Services Case Management Compliance Program/Provider shall provide one or more core transition services, specifically Vocational Services and /or Education Services, including mentoring and transportation with related support services. Twenty-seven open youth records were reviewed. Two were applicable for referrals, due to services being identified. Within fourteen days of the referral being made, the transition specialist completed a follow-up with the youth to ensure services were rendered and subsequently every two weeks thereafter. Documentation in each of the twenty-seven youth records included a community action team (CAT) within ten days of the initial contact and monthly face-to-face contacts. Of the twenty-seven open youth records, seventeen were Office of Program Accountability Page 12 of 14 (Revised July 2015)
assigned a life coach. The transition specialist, in collaboration with the life coach, made faceto-face contacts every two weeks. The ten remaining youth not assigned life coaches, met with the transitional specialist every two weeks. 3.04 Release/Discharge Compliance Prior to release or discharge of a youth from services (prior to completion of the intervention) the Program/Provider must coordinate discharge planning with the youth s JPO. Eleven closed youth records were reviewed for this indicator. Within the eleven records, documentation included the transition specialist coordinating the discharge prior to completion of the program. Coordination began thirty days before the youth s anticipated release date. An exit meeting, with the youth and their family, was conducted by the transitional specialist. A discharge summary was completed by the transitional specialists and submitted to the area director. The area directed signed and acknowledge reviewing the discharge summary and the discharge summary was then entered into the Juvenile Justice Information System. Office of Program Accountability Page 13 of 14 (Revised July 2015)
Program Name: Project Connect MQI Program Code: 1307 Provider Name: Twin Oaks Juvenile Development Corporation Contract Number: 10013 Location: Leon County / Circuit 2 Number of Beds: Review Date(s): February 22 & 23, 2017 Lead Reviewer Code: 122 Overall Rating Summary Overall Rating Summary All indicators have been rated and no corrective action is needed at this time. Office of Program Accountability Page 14 of 14 (Revised July 2015)